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There is no need for fear as we are only doing what we must. To be apathetic is to be selfish and derelict in our duty to our children and our children's children!
Huang Shoou Chyuan

Friday, December 01, 2006

New Medico-legal framework helps us avoid pitfalls of Defensive Medicine

New resolution framework allows early settlement of medical negligence cases

By Dominique Loh, Channel NewsAsia Posted: 29 November 2006 2036 hrs

SINGAPORE: Starting next year, patients will have another avenue to seek resolution in a medical negligence case.

The new framework gets patients to talk to their doctors early, so they can settle a case before it goes to trial, which translates to huge savings in legal costs.

The number of medical negligence cases in Singapore is considered relatively small with an average of about eight to nine cases a year. 97 percent of these cases are settled before they go to trial.

In 2003, there was a peak of 20 cases but 94 percent of the cases never went to trial.

Last year, 87 percent of the 11 cases were settled out of court.

In the first ten months of this year, five cases were reported with one settled while the others are still in the early stages.

This has not stopped the courts from pre-empting court cases through this new protocol which starts in January.

Before even going to court, patients or their relatives will be required to talk to their doctors to seek explanations.

This means both parties communicate early so claims are more likely to be settled.

Such a system will also discourage frivolous or cases without merit. Lawyers say such cases could have racked up legal fees in the hundreds of thousands of dollars.

Toh Han Li, Registrar at the Subordinate Courts, says: "What has happened in the University of Michigan healthcare system is that they've instituted a programme to be more open and communicative by giving more information and talking with the patients.

"As a result of this programme, the number of lawsuits dropped by half in one year and there was a great deal of savings in legal costs. The number of lawsuits dropped from 261 in one year to 114 and there was savings of, I think, a few million US dollars as well in legal costs."

Dr Lee Chien Earn, Health Performance Group at the Ministry of Health, says: "I think what it will do is it will help serve as an additional avenue for patients and healthcare institutions, providers and doctors to communicate and to better understand each other's position.

"I think doctors would be supportive of this because it gives them an opportunity to explain their decisions and to explain what has happened. Both parties come from different perspective. It's when you bring them together that they start to understand what the underlying concerns are."

I will keep my comments brief and to the point as I do not have the luxury of time (I got an exams tomorrow).

Let me say that I am extremely proud to be a member of Singapore’s medical fraternity. Notwithstanding some “black sheep”, I can truthfully say- hand to heart, that our doctors are well-trained and sincere and do try their utmost to help their patients.

My praise is not just accorded to doctors in the private sector but also to government-employed doctors.

However, despite good intentions, the result of any treatment (surgical or not) may not meet the patient’s expectations. Even in the best of hands, complications may not be avoidable.

The new proposed structure is beneficial for our society as it reduces unnecessary lawsuits.

When we go down the route of excessive litigations, the end result would be more expensive medical expenses as we doctors would be forced to practise ”defensive medicine”. I am not ignoring the fact that with the threat of lawsuits, doctors no longer think of themselves as demi-gods not answerable to anyone. They have become more responsive to the needs of patients and give fuller explanations to patients and do get “informed consent” before any procedures) etc.

However my humble opinion (albeit skewed as I am an interested party), is that the net result is healthy (no pun intended).

If the sole aim in my practice is the avoidance of litigation (and hence adverse publicity), I would have to scan every brain ( I mean patient’s brain) that walks into my consultation room complaining of anything remotely connected to the part of the anatomy between the 2 ears.

But seriously, does everyone with a headache or giddiness need an expensive MRI Brain Scan? The answer is “Yes” if you practise in New York or LA.

I am not advocating a cavalier or irresponsible practice of medicine. The doctor-patient relationship which is based on trust and rapport needs the support of our community and society.

Doctors are human too. We empathise with our patients’ financial hardships and hence, I do find myself saying to my patients thus, “ Although your giddiness theoretically can be due to a small vestibular nerve neuroma, which is detectable in its early stage only with an MRI Brain, the chance of this is small (if it is indeed small). ” I do add the caveat that “if you want 100% certainty” ( or in other words- cost is not a concern), I will arrange for the Scan straight away, now, stat, pronto etc.

But, “if you trust me “( or trust that I am trying to help you without spending money unless really required), - not that you don’t trust me if you want to do the MRI Brain anyway, we (patient and I) will find a cure for your ailments in the most common sensical way.

However, if at the end of the day, some sub-optimal outcome occurs, and the patient is not convinced that the “complication from surgery” (or delay in diagnosis) is unavoidable, then let us talk about it. And try to sort out any issues before resorting to any legal process which will cost the whole of society a lot of money. Of course, some lawyers will bring home more bacon for the table but let’s not digress.

I am still trying to grapple with the impact of this new arrangement.

The jury is still out (in our doctors’ tearoom) whether this will make the practice of medicine closer to what good ole’ Hippocrates meant it to be.

The bottomline is:Docs are humans too. We do try our damnest. Can’t we just talk about it when things don’t work out?

As I had mentioned in my post about this new mediation process, it is a good first step. However, from experience of dealing with such things, cases are oftentimes very complex, involving not only the medical aspects, but also the emotional as well as monetary ( the latter playing a VERY large role). As u know, things happen - complications of a disease process or of a surgical process, risks are never zero for any procedure; & due to either sheer ignorance, absoute (& unrealistic) trust in the miracle of medicine/doctors & lack of communication, when adverse events DO happen, the blame fest starts...especially when patients or their relatives are faced with a large bill to pay.

Communication has a huge role to play in practising good medicine...not after the fact, but as part of the process of treating the patient.

From my POV, an admirable first step...but there's a long way to go. Both Doctors AND Patients have to play their part.

You may be a good doctor (I'll give you the benefit of the doubt), but certainly make a poor lawyer. You seem to be confusing making doctors liable for negligence and enforcing that liability in court. I'm sure you agree that doctors should be made liable for their negligence. This will not lead to doctors scanning every brain because liability is not strict (absolute), ie it's based on what a doctor of ordinary prudence and skill would do in the circumstances (the reasonable doctor test). No court will expect a reasonable doctor to scan every brain. And even liability were made absolute, a doctor would still weigh the cost of liability (including loss of reputation) versus the cost of scanning every patient's brain. Assuming only one in 100 patients really need the test ie it would make a difference to the treatment of the patient, and the tests costs more than 1% of the cost of liability, then I'm pretty sure the doctor would choose to take the chance and compensate the 1 patient for every 100 he sees rather than take on the additional tests.

I would certainly agree that allowing extra avenues for settling out of court is of course a good thing since litigation is a very costly business that benefits no one except the lawyers. That is provided of course that the doctor and the patient can reach some agreement on the amount of settlement. This will necessarily be somewhere between what the doctor and patient respectively think they are likely to pay out and receive respectively if the matter were decided in court, taking into consideration the uncertainty and cost of litigation. And this explains why sometimes settlement out of court may not be possible and resort to courts is necessary.

HiWhispers: It is true that there is a lot more info in the public domain easily available in cyberspace. However usually only those found in sites hosted by reputable organizations like U’s and National/Int’l medical bodies are reliable. The NUS admission boards for med school generally try to select undergrads who really have aptitude for med and usually this includes empathy for patients. But as you know, choosing suitable candidates is always an inexact science and still many who should never be doctors do get through this sieve. Yes it is a higher calling but doctors are human too. So forgive us our trespasses.

Dr oz bloke: Yes, the doctors we get in S’pore may be a reflection of the type of society we have become. Sigh!

Aliendoc: Yes I agree that communications is paramount in doctor-patient relationship esply if the treatment outcome is not optimal.

George: You have brought me down to earth. S’pore and much of modern society is still very litigatious so we will still scan more brains than actually necessary, for the patient pays for it. That will make X-ray clinics very happy. Thanks for the reality check.

The new medico-legal framework takes its cue from the practices put in place by the U of Michigan Health Services in response to the rapidly escalating malpractice premiums for physicians in the USA.In Miami Dade county, the premiums for high risk specialties like OBGYN runs US$ 250,000 , and for neurosurgeons US $300 to $400 grand a year. Coupled with shrinking returns from payers to physicians because of legislated Medicare rate reductions and rising costs of practice had resulted in high risk physicians moving away from litiginous areas . As a result, these areas are underserved.The payout for malpractice claims are legendary high in the USA and insurance companies raise both the premiums for physicians and patients to recoup losses.This is a double whammy for the physicians and patients.As a result the USA is seeing more people not carrying Health Insurance, because they just cannot afford to.It seems that the only gainers are lawyers who are doing all they can with the passing of self serving laws to keep the status quo.. like the 3 strikes and you are out law passed by the legal lobby end 2004 in Florida.. there a physician will lose his license if he is sued 3 times and had put up a defence in court, irrespective if he succeeds or not.. on the other hand, a physician who settles out of court will not be counted against.In 1999, the Institute of Medicine disclose the figure that there were 98,000 deaths from medical errors a year in the USA.( this figure is still debated). Anyway, 90% of these deaths were the fault of systems and procedures and not due to physician negligence.The traditional response by hospitals and lawyers when a malpractice claim is put out to the physician was to keep silent as any admission or apology will be construed as an admission of liability.The only way aggrieved patients and relatives can get any revelation of what really happened was a costly court action.Medical Practice is not an exact Science and medical errors will happen, and a dissatisfied outcome is not necessarily a negligence.The law of tort and contract developed from common law cannot always be applied in its full extent in Medical Law: the test of reasonableness in the Bolam case and now later case precedents is determined by layjuries, most times not truly understanding the medical and legal intricacies, with colossal awards resulting from sympathy and greed rather than correctness - a plague in US court decisions.Many physicians are devastated when their patients suffer an adverse outcome..they experience selfdoubt, depression and deep remorse,and their families suffer with them; suicides and giving up practicing are common... I have not heard of a lawyer doing that when he lost a client to the gallows or when he puts someone and his family into bankruptcy..Many physicians do not wish the harm done to their patients....The aim of the UofM scheme is to facilitate the investigation into and not deny any medical errors. They do so with the cooperation of the patient and his legal counsel;to mediate a settlement without costly ,protracted and uncertain court proceedings.This will cut down legal costs which takes away 70% of the awards given out by courts.It allows the quick and full allocation of compensation to injured patients, without having to wait the outcome of the courts which takes years in the US. Immediate review into the system to correct shortcomings and faults are carried out by the Health system, insteading of sweeping them under the carpet as was the norm in the past.Frivolous lawsuits are removed from the system.The savings accrued by the insurers are required by law to be passed as reduced premiums to patients and physicians. Hopefully the Defensive medicine pysche, maybe alleviated because of a less confrontational doctor-patient relationship.How all of these will play out in the Singapore scene will, I surmise not be intrinsically different.Patients will have their medical errors appraised very soon and due compensation awarded without the fear of high legal cost hanging over their heads ,like an albatross.Unlike,US lawyers, Sing lawyers do not work on contingency fees. This may have been a damper for many patients to seek compensation in the past, but they may do so more readily now. Physicians on the other hand are spared the cruel media publicity.Patients can still bring the case to court if they feel that the process is not working in their favor.I see a win win situation.

Hi travailingdoc,Thank you for comprehensive and convincing comments.It is strange how baseball language gets into all this.Now, whenever I hear "Strike 3 & you're OUT", you can imagine me trembling in my shorts".Isn't it any wonder that most of my doctor friends and I actively discourage our own kids to take the same career path.Unless measures like the above succeed and restore some sanity to doctor-patient relationships, we will also go the way of the USA, where you can't find OBGYN/trauma surgeons/neurosurgeons in some states! Even if you can find them, the charges for any surgery by them would be too exorbitant and this could be traced to astronomical punitive damages meted out by the law courts.Well, let's just see how all this pan out.Cheers

you doctors have nothing to worry about if u all sincerely do your job to the best of your abilities. Your conscience is clear, and dats wats important. However the issue here is the legislating coming in, preventing the other party the option of litigation if they desire, whether rightly or not. Taking away that option is like protecting the doctors. Why protect them?

Let me tell you that this odds thing eg 1 in 100 etc doesnt cut any ice in reality.

I had a friend who saw a lady who had been involved in an RTA. Motorcyclist. When the ambulance went to the accident site she was sitting by the roadside.

Went to A&E complained of headache but there was no history of loss of consciousness. GCS was 15 .Her relative was there and asked the doctor if she would CT scan her head. The doctor felt it was unecessary. But the relative made a big fuss saying what would happen if she had a 'serious' injury etc.

So the A&E doctor relented and agreed to admit her.

Within 30 minutes of going up to the ward,(do remember it takes time to get the bed etc), her conscious level started to decline. She was wheeled to the CT scan room urgently but died there.

Well I don't have to say much more except that the relative wrote several letters and wanted to sue and all.

This sort of case is what terrifies us doctors. Does it happen frequently? No. Probably 1 in a 1000 or 10,000. But if it happens...well it's someone's wife, sister, daughter. Do they have a right to be angry? Yes they do.

Does the doctor who happened to be unlucky enough see her have to answer to the enquiry? Yes he/she does. Is it pleasant? No. Is the doctor negligient? Well probably no (as George rightly pointed out it's a question of probability)

But when I saw that case, and the mental turmoil and torture my friend went through, I realised it could have easily been any of us doctors working that day. Luck of the draw.

At the end of the day, what's the REAL cost of doing a CT or MRI for EVERY patient with a head injury of any kind?

It depends on who are the ones paying.

Hindsight is always 20/20. I am sure the administrators would say "if only we had CT scanned that lady", the doctor would also have said to herself "if only I had CT scanned that lady". But it's a probability.

Here's what I think as a doctor.

If we doctors all did CT scans for every headache or head related symtpom....well the chances of us being found negligient for any head problems would be very low. Basically if you do EVERY darn thing there is to do, then how can you be negligient? But the cost of healthcare would go up.

But I would rather spare myself the torture of having to explain why I did not do the test for that ONE unfortunate and unlucky person and leave the large healthcare bill to the politicians to sort out.

After all when such and event happens are there people who come out and say "don't blame the doctor he is helping to keep the healthcare costs low...."

oh dear, recruit ong, if only it were as simple as that...doctors do not set out to cause harm to patients. Docs are humans too - they make mistakes too; bad luck also happens - nothing is guaranteed in life & in medicine. A simple procedure could lead to a life-threatening infection. And when such things happen, a doctor (being human) would also feel guilty although the event may not be his/her fault at all. I don't think this new process is meant to do away with litigation entirely...just helps to save on cost & hopefully enhance communication between the parties involved...

oh well then consider it occupational hazard lor. As a society gets more educated, it is normal for patients' expectations to increase. All jobs out there have their own kind of risks, no exceptions for doctors too. As things stand now from the cases reported in the papers (NS soldier died after doctor accuse him of malingering etc etc etc) even what seems like clear cut cases of negligence to me, the doctors involved still got away scot free, with their fellow professionals testifying in the witness stand as experts. So, really, i just don't see why the elite class of society needs to get further protection. Unless all this is an anticipatory move.. dat we will soon see influx of cheap FT doctors? and there is expectation that medical standards will drop as a result???

recruit ong You are right.. standard of medical care will fall and there will be more FT doctors..Defensive medicine is a scourge not for the doctors but the price is borned by society.High costing procedures not without risks are carried out to appease and to preempt possible lawsuits. They subject patients to unneccessary tests from which patients had died from.The cost of medicine spiral up depriving many people from health care.Medication costs are exorbitant and outrageous because drug firms have to pay millions out as compensation.Yes doctors do take it in their stride that Malpractice is real... Hey... We live, breath and eat it on a daily moment to moment diet.Yes other occupations have also their risks, and so they too take up defensive positions... soldiers shoot back or be killed..the dead soldier is given a ceremonious burial and his expected pay and compensation given to the family..no majestical fanfare.

The brightest and the best will not take up medicine but would rather be bankers and wall street punters.. so you will have to content with second stringers. Physicians go into early retirement or avoid procedures that are high risks

I am not giving you a speculated and hypothetical scenario. I see this everyday in my practice here in the land of the brave...delayed MRI because a patient's insurance will not pay for it and he dies as his cancer festered and grew. Non paying Patients crying out in agony and pain as I have to transfer them away from the private hospital to the county one where care is dubious and substandard.Senior citizens cannot fill their prescriptions because their health plans do not provide them.Generic drugs are substituted to save costs.Are doctors elitist??...not any more.. certainly not in the minds of the ones I know and as I can see in this forum..This is a social phenomenon that affects all and not just doctors..Until it hits home you have just no idea

Hi all,It seems there are detractors from both sides of the argument not only in this forum but also in the docs tea-room.Contrary to recruit ong's fears, some drs think that this new framework actually makes it easier for patients to bring any complaints against drs as it will cost much less arranging for a meeting now than previously when they needed to engage a lawyer before proceeding further.Humans are always more comfortable with status quo than of a new "unknown". What did Rumsfeld say about the "unknown unknown"?

Good point about the increase in complaints. I am sure that will be the case.

However think of it as give and take. I only hope the doctors know what to do when they meet the relatives/patient. Don't give away ANYTHING. Just apologize.

There will be more such "meetings" but probably less actual lawsuits. The key is not to turn the meetings into investigative fact finding missions for them to gather information to use against you in court.

The bottomline is this. Lawyers are two headed. They can quote you one thing when they are on your side. But the very same lawyer could quote something different and against you once he is on the OTHER side.

Trust no one.

I'm still for practising defensive medicine. Like I said, nobody ever thanks the doctors for not practising defensive medicine in order to save costs.

"The brightest and the best will not take up medicine but would rather be bankers and wall street punters.. so you will have to content with second stringers. Physicians go into early retirement or avoid procedures that are high risks"

this sounds exactly like the PAP reasoning being used to justify ministers salaries. That we would not get the best and the brightest yada yada etc etc. Worse yet, u will suffer if u dun pay them enough! It is like blackmail and doing the profession a great dis-service. To reward them (or in this case protect doctors) thinking they may be good at it totally makes no sense. Really if a person wants to make a ton of money and sees being a doctor as the mean to reach such a goal, then perhaps the doctor profession is not for him/her. That is not to say that doctors aren't well paid. As in all professions, those who reaches the top of the pile thru their dedication and hard work are rewarded well. But i like to think that monetary reward (or protection from negligent suits) isn't the starting point.

Being a doctor is just a profession. You don't have to hate us. We are not Gods and do not ask to be Gods. How much we are paid depends on how well we serve our patients. Trust me, if you are a lousy doctor you earn less. Lousy doctors do not earn MORE than good doctors. Of course what is "good" and what is "lousy" varies from patient to patient.

At the end of the day, doctors are also human. Do humans make mistakes? Yes they do. If your mechanic made a mistake and damaged part of your car engine, he can offer to replace the part FOC.

In medicine you can't do that. And the only course of action? Legal suit.

Of course one would argue that is why we pay doctors so much money.

But really do you believe all the stuff that "they" say about how much you pay = get the best = perfection?

Think logically, no matter how much you pay a doctor and how "good" the doctor is, the doctor is ultimately still human. Only God can change that. No amount of money can do it.

And humans can make mistakes. People just can't accept it.

I know because my own father insisted I should be perfect and he still believes surgeons are perfect.

I sense we are on a different keel here..If monetary pursuits are the only and all, many would have left the medical profession long ago...My point was about Defensive Medicine and its pitfalls .. the issue of why people do take up medicine remains another debate.I rest my case.P.S I am no PAP fan, that is why I am a quitter..

"The PAP is merely a political party. Singapore is the country. The governing political party can change. But yet we quit Singapore (we don't quit the PAP if you think about it)"

however when a country is intertwined so tightly with one political party, like in the case of Sg and PAP, then the 2 becomes indifferentiable. The PAP deliberately wants this (read LSL ypap speech), it is good for them. Think of it as the country being hijacked by the PAP, or kidney patients being held hostage by NKF, so that as and when it is convenient they invoke the name of the country, like a human shield, to advance its own political objectives. And it works, many Sgians simply cannot imagine a Singapore without the PAP. Even the late Rajaratnam had made it clear in the past that the story of Singapore must begin with the PAP and is the PAP Story. That's national education for you.

To undo this unhealthy malaise, therefore it sometimes becomes necessary to be 'unpatriotic', to be a quitter, in order to free ourselves from this pyschological chain. (And it is not necessary to be physically somewhere else to be a quitter.) It is actually better and healthier for Sg in the long run.

"Quitter" an interesting PAP hyperbole of course. I take it with a pinch of salt.Moving overseas and starting all over again is no mean feat. It requires endurance, courage and commitment. We left behind secure jobs, families and homes. There are problems of adjustment, job placement, acculturation and even discrimination. So, to leave Singapore because we " quitters" are supposedly too weak in character but will take on a much tougher option ( emigration) instead really makes "quitter" in the PAP sense an oxymoron.Ironically, the PAP had done me a favor.... because myself and my family have come to love this land of the free...we see many others in this same "unfortunate" happy plight.So,really, this is loss to Singapore, because these are people who will survive, and will not remain to be pandered to and bottle fed with PAP tripe.

Hi recruitong/droz/travailingdoc,You are all most welcome to comment on my blog anytime.It is normal to have difference in opinions. We (Singapore) should learn to be tolerant of those who hold different views.I am glad that travailingdoc is happy that he is now part of the land of the free. Only when one sees his homeland from afar can one get the proper perspective.If we have only been on this red dot, we think that the only way things are done are the way that the govt and system had taught us!Those of us who are still around here, how do we contribute in making this place better ( not in the sense of joining the Pap or the community centres)? Personally for me, friends and family are impt. I try to be involved in my working community ( ie involvement in committees that run the hospital and medical specialist society etc). I don't believe in sucking up to anyone, hence I don't do things to get recognition and the BS. I believe ( or am I wrong?) that volunteerism is a given in the land of the free?Sorry I am way off the topic.Maybe I will blog something on this later.Cheers

Immediately springing to my mind is St. Judes Institute for Cancer Research in Children.It is entirely a charitable organisation dependant on donations alone and was founded by the late actor Danny Thomas.I first heard of it was when I diagnosed a black 10 year old boy with Nasopharyngeal Cancer ( yes you heard right) and the local oncologist suggested referral to SJ.So, we did all the preliminary tests and sent them across to Tennessee and within a week, the child and mother were both flown to Memphis all expenses paid for and put up in the community and received treatment for the 6 weeks.I was impressed. All donated dollars are returned to patients and running costs and salaries are kept minimal as the staff are sensitive to the higher cause that they are serving. None of the NKF BS machinations of accumulating assets and market rate CEO salaries.The institute is at the frontier of research and advancement and has worldwide recognition as a Mecca for children cancer.The website is available and donations are welcomed.Doctors organise tours to South America for missions.There are free clinics run by volunteers for the poor and many medical offices do not turn away the needy.The people of Singapore are generous .. its the Govt who has a twisted and perverted sense of charity.

Hitravailingdoc: It is great to know that charitable institutions still exist to give worldclass care for the needy. I wonder if the CEO's do get market rate ( or should I even ask)? I am sure just making people happy is more than half the reward. In S'pore (sigh), only money talks and only the most dogged will get off the trodden path.

drozbloke: Ya, I know. After this weekend I will write something new possibly on what PM said about making foreignors and PR's pay more for healthcare/education etc.Very busy past week. Sorry

It is good that the government set up this rule. The doctors primary function is to cure the sick. It is a high calling. My cousin was offered a chance to the doctor course in NUS, which he turned down. he felt not up to stress to answer to a patient's kin if he was unable to cure the patient. Moreover, he felt it is a life time profession which means a lot of heart.

It is not easy to be a doctor.

Concentrate on healing. that i feel is the general idea behind this law.

About Me

I am a doctor.
Everyone,even doctors,has a say in how Singapore is run. (But saying is one thing and getting someone to listen is something else).
For the sake of society, someone has to push the boundaries and seek out the OB (Out-of-bound) markers. So why not me (or is it I)?
About comments:
While you are free to post your comments here, your comments do not represent my views. In the event that any of your postings are deemed to be offensive or unsuitable for public viewing, as the author of this blog, I reserve the right to remove them.
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